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Medicine is filled with uncertainty. Clinicians may experience uncertainty due to limitations in their own or existing medical knowledge. Uncertainty can be scientific, practical, or personal, and may involve issues related to probability, ambiguity, and complexity. Pediatricians face additional uncertainties related to the role of families in decision-making and limited ability to know the preferences of children. Clinicians may approach uncertainty in different ways: some choosing to embrace its presence and others attempting to avoid it. Ultimately, pediatricians must learn to navigate uncertainty together with their patients and families, minimizing it when possible while accepting that its presence is unavoidable., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Clinical ethics is the dimension of bioethics devoted to analyzing competing values and obligations in clinical care, seeking the optimal balance between competing duties. Competence in clinical ethics is particularly important in our current scientific and social environment, where disharmony and challenges between value systems are common and the medical profession suffers from self-imposed risks to integrity and coherence. The ability to bring ethical analysis into the challenges of everyday clinical practice is a crucial component in resolving values conflicts and protecting the clinician-patient relationship that is the heart of our profession., Competing Interests: Disclosures No disclosures to report., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Objective: To determine the effect of severe acute blood loss anemia (ABLA) on postoperative outcomes in Jehovah's Witness (JW) patients undergoing cardiac surgery., Design: This was a retrospective cohort study of adult JW patients undergoing cardiac surgery requiring cardiopulmonary bypass (CPB) between January 1998 and December 2018 at Barnes-Jewish Hospital in St. Louis, Missouri., Setting: At a single tertiary academic center., Participants: Patients who were JWs undergoing cardiac surgery requiring CPB., Interventions: Patients were divided into the following 2 groups: JW patients who developed severe ABLA (defined as postoperative hematocrit level <21), and patients who did not develop severe ABLA., Measurements and Main Results: A total of 48 JW patients who underwent cardiac surgery between 2008 and 2018 were identified. Of these patients, 9 (18.8%) developed postoperative severe ABLA, and 39 (81.3%) did not. Severe ABLA was associated with increased postoperative mortality at 30-days, 90-days, and 1-year postoperatively, and a trend toward increased hospital length of stay., Conclusions: Severe ABLA after cardiac surgery was associated with higher mortality and a trend toward increased hospital length of stay among JW patients. More data are required to confirm the findings., (Copyright © 2022 Elsevier Inc. All rights reserved.)

The Division of Cardiothoracic Surgery at Washington University evolved a century ago to address what many considered to be the last surgical frontier, diseases of the chest. In addition, as one of the first training programs in thoracic surgery, Washington University has been responsible for educating more thoracic surgeons than nearly any other program in the world. Beginning with Evarts A. Graham and continuing through to Ralph J. Damiano Jr., the leaders of the division have had a profound impact on the field of cardiothoracic surgery., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Acute aortic dissection is a fatal disease if early diagnosis and institution of appropriate therapy are delayed. Unfortunately, the presentation of a dissection can be diabolical, leading to an initial misdiagnosis in more than 25% of patients. For type A dissections, surgical repair is essential because mortality rates approach 50% at 48 hours with expectant therapy alone. For type B dissections, medical management is successful in most patients, although a subset with complications or early dilation may benefit from newer endovascular techniques. The goal of this review is to summarize the diagnostic algorithm, initial therapeutic options, and long-term management regimen that offer patients with an acute aortic dissection the best chance for short-term and long-term survival. There is an emphasis on the specific practical approach that is applied at Washington University to patients who present with an aortic dissection.

Objective: The purpose of this study was to investigate if the preoperative use of new platelet inhibitors and low-molecular-weight heparins may contribute to bleeding after cardiac surgery., Design: Retrospective data review., Setting: University teaching hospital., Participants: One hundred eleven patients divided in 5 groups., Interventions: Patients were grouped according to preoperative antithrombotic regimen: group 1, control, no agents (n=55); group 2, clopidogrel (n=9); group 3, enoxaparin (n=17); group 4, any GP IIb/IIIa inhibitor (n=14); and group 5, any drug combination (n=15). Data included cumulative mediastinal chest tube drainage, allogeneic blood transfusions, total blood donor exposures, and re-exploration., Measurements and Main Results: Use of any drug (groups 2-5) resulted in greater total blood transfusions and donor exposure (p=0.0003) than control, especially red cells (p=0.002) and platelets (p=0.006). A greater percentage of patients on enoxaparin required mediastinal re-exploration for nonsurgical bleeding versus control (3/17 v 0/55, p=0.001). The use of enoxaparin was associated with significantly higher chest tube output after the first 24 hours postoperatively (p=0.048)., Conclusion: Newer antithrombotic agents were associated with greater transfusion rates and total donor exposures. Enoxaparin use was associated with greater overall blood loss and with higher incidence of mediastinal re-exploration. The relative risk-benefit ratio of reduced periprocedure morbidity versus increased bleeding complications has yet to be determined.